Electroconvulsive Therapy For Obsessive Compulsive Disorder

Introduction

Electroconvulsive therapy (ECT) is a type of therapy that involves inducing controlled seizures using electric currents, done in patients under sedation or anaesthesia. It's primarily indicated for severe depression but may also benefit other mental conditions. ECT is often stigmatized because of misinformation and historical concerns about its side effects. However, the practices nowadays have evolved and minimised risks.^1,2

More recently, studies have shown the benefits of ECT for serious psychiatric conditions, such as:²

• Obsessive-Compulsive Disorder (OCD),
• Parkinson’s disease psychosis,
• Malignant neuroleptic syndrome,
• Post-traumatic stress disorder (PTSD).

In this article, we will discuss the rationale for using ECT to treat OCD, its efficacy and considerations and controversies.

Understanding OCD

What is OCD?

OCD is a mental disorder characterised by:^3,4

• Obsessions - intrusive and unwanted thoughts, that typically induce anxiety. 
• And compulsions - repetitive behaviours or mental acts, driven by rigid rules or a need for 'completeness’

Common obsessions and compulsions in patients with OCD include:³

• Concerns about contamination and washing or cleaning, 
• Concerns about harm to self or others and checking, 
• Intrusive aggressive or sexual thoughts and mental rituals or praying, 
• Concerns about symmetry and ordering or counting,
• Hoarding concerns and hoarding behaviours.

Prevalence and impact of OCD

Previously, OCD was considered rare, but surveys show that 2-3% of the population, at some point in their life, experiences OCD, with variations across regions. OCD affects individuals irrespective of socioeconomic status or gender, though it is more common in people assigned female at birth (AFAB). This disorder typically starts early in life, with 25% of people assigned male at birth (AMAB) experiencing symptoms before age 10, while those AFAB often develop OCD during adolescence or postpartum. The disorder tends to persist over decades, but the disappearance of symptoms is also possible.^3,4

OCD frequently occurs with other psychiatric disorders, especially anxiety and mood disorders, and is associated with reduced quality of life, and impaired work, family, and social activities for both patients and their caregivers. Therefore, early recognition of OCD and interventions are crucial for better outcomes.^3,4

Conventional treatments for OCD 

The treatment of OCD involves a combined approach tailored to individual patients. It begins with:^3,4

1. Establishing a therapeutic relationship, providing psychoeducation, 
2. Followed by considering psychological and/or pharmacological therapies,
3. And neuromodulatory/neurosurgical interventions for treatment-resistant cases. 
4. Other alternative therapies exist but require further evidence.

The most recommended psychotherapeutic approach for OCD is Cognitive-Behavioral Therapy, particularly Exposure and Response Prevention, which involves gradual and prolonged exposure to stimuli that induce fear, combined with instructions to refrain from the compulsive behaviour. It has been shown to significantly improve symptoms in both adults and children.^3,4

Regarding pharmacological treatment, antidepressants are the most indicated for OCD due to their efficacy, safety, and tolerability.^3,4

Despite the effectiveness of those treatments, approximately half of patients may still present symptoms and modifications, and other interventions may be necessary, especially for people with other conditions like depression or bipolar disorder.^3,4

How does electroconvulsive therapy work?

Explanation of ECT

ECT  is usually performed in settings such as dedicated suites, post-anesthesia care units, or ambulatory surgery sites. Patient preparation before the procedure includes:¹

• No light meal for six hours, 
• No full-fat meal for eight hours,
• No clear liquids for two hours before anaesthesia.

During ECT, vital signs and various physiological parameters are continuously monitored and a bite block is placed for the patient’s tongue and teeth protection.¹

Then, electrodes are placed on the scalp and the electrical stimulus is delivered. The stimulus can either be a brief pulse (from 0.5 to 2.0 milliseconds) or an ultra-brief pulse (less than 0.5 milliseconds). The standard choice is the brief pulse, but the ultra-brief pulse is generally considered more tolerable. The electrical dose is based on the minimum intensity of a stimulus required to induce a seizure in the patient.¹

After the patient is unconscious, due to the stimulus, a muscle relaxant is administered and ventilation with 100% oxygen via a mask is supplied. Overall, the procedure goals are to ensure a safe and pain-free experience for the patient while optimising therapeutic outcomes.¹

Mechanism of action of ECT

There are different hypotheses regarding the mechanisms underlying the therapeutic effects of ECT across various psychiatric disorders. These hypotheses are based on findings indicating changes induced by ECT such as:^2,5

• Structural - ECT has been reported to act on the neuronal structure volume, promoting the formation of new neurons in brain structures like the hippocampus and the amygdala. 
• Functional - ECT changes the activity of the cerebral cortex. During ECT, there is an increase in blood flow, glucose (sugar) metabolism, and oxygen consumption in the cerebral cortex. After that, there is a period of blood flow decrease as well as brain glucose metabolism, which is associated with ECT efficacy in depression treatment 
• Systemic, including alterations in the endocrine and immune systems. ECT can decrease cortisol (known as the “stress hormone”) levels. Furthermore, it has been proposed to regulate inflammation of the immune system, which is observed in some psychiatric disorders.

Efficacy of ECT in treating OCD

It is important to note that ECT is not included in current treatment guidelines for OCD as a therapeutic alternative. However, various studies have reported positive responses in patients with treatment-resistant OCD. Literature reviews and case studies have shown significant improvements in symptoms, remaining 1 year after treatment in some individuals.² For example, one quasi-experimental study involving 12 adult patients with severe OCD and no comorbid psychiatric disorders found that ECT, consisting of sessions administered 3x a week for up to three to four weeks, was a safe and effective therapeutic strategy.⁵

Nonetheless, the evidence supporting the use of ECT for OCD is limited due to the absence of better-controlled studies, the small number of participants, and study design issues in existing research.²

Considerations for ECT

Side effects and patients at risk of ECT complications

Research suggests that while ECT is generally well-tolerated and has a low mortality rate, some side effects can occur, such as:^1,5

• Confusion
• Delirium
• Disorientation
• Memory loss

These cognitive impairments following ECT are particularly observed in bilateral or bitemporal ECT, though these effects are typically transient.¹ 

Also physiologically, one of the phases of a seizure during ECT can lead to bradyarrhythmias, while another phase may result in tachycardia and hypertension, which usually resolves shortly after the seizure.¹

Patients considered at higher risk for complications from ECT include those with:¹

• unstable or severe cardiovascular disease,
• intracranial lesions, 
• pulmonary diseases,
• high American Society of Anesthesiologists (ASA) classification, a system to determine the person’s health before a procedure that requires anaesthesia

Considerations for better ECT outcomes

For better outcomes and safety of ECT, it requires a well-trained team of healthcare professionals, consisting of nurses, anesthesiologists, psychiatrists, and neurologists.¹

Another important factor is the education of patients and their families, due to misconceptions surrounding ECT, associated with false and illogical beliefs.¹ 

ECT can be used in pregnant patients and the elderly to avoid side effects of psychotropic medications. However, in pregnant patients, hyperventilation (rapid and deep breathing) should be avoided because it can reduce the adequate supply of oxygen to the foetus. Minimising fasting time and adequate intravenous fluid hydration are essential to avoid dehydration and premature uterine contractions. Depending on the time of gestation, other precautions must be taken, including foetal heart rate and uterine activity monitoring before and after each treatment.¹

Stigma in patients receiving electroconvulsive therapy

Stigma comprehends negative attitudes and discriminatory judgments from a majority group against a minority, for example, those with mental illness. Besides social stigma, people can also have internalised stigma, when they adopt negative messages from society and apply them to themselves, which leads to:⁶

• Reduced self-esteem
• Impaired social relationships
• Self-isolation
• Reluctance to seek treatment
• Job abandonment
• Diminished opportunities for independent living. 

ECT also faces high levels of stigma due to misconceptions about its safety and effectiveness. Mostly because negative portrayals in the media, historical practices, and fears about memory loss contribute to public mistrust and reluctance to accept ECT as a viable treatment option. Therefore, addressing these misperceptions is crucial for promoting the acceptance and accessibility of ECT for people who might benefit from it.⁶

Summary

ECT was primarily a treatment option for severe depression but is now also used for other psychiatric conditions, including OCD.^1,2 This mental disorder is characterised by obsessions and compulsions and affects approximately 2-3% of the people in their lives. OCD treatment involves a combination of psychotherapy, pharmacotherapy, and neuromodulatory interventions. However, about half of patients may still present symptoms.^3,4 Thus, while ECT isn't included in current OCD treatment guidelines, studies suggest benefits for treatment-resistant cases, albeit with limited evidence.^2,5 ECT carries some risks, including cognitive impairments and physiological effects, especially in certain patient groups.¹ Because of the risks, misinformation and stigma surrounding ECT exacerbates reluctance to accept it as a therapeutic option.^1,2,6 Addressing misconceptions is vital for promoting its acceptance and accessibility, enhancing treatment options for individuals with psychiatric disorders, including OCD.⁶